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APPL1;A11UR tUX etKM11 bAN JUAMN LUUAL HOLIN UIbIKIUI <br />UNDERGRG�ANK- e Ml E HAZELTON AVE.,STOD:TOI <br />N <br />CLOSURE OR DONMENT Telephone (209) 4E8-3420 <br />....................... <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE FACILITY <br />THIS.PERMIT EMPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />/REMOYAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br />IWI'11("l <br />EPA SITE I PROJECT CONTACT & TELEPHONE 4 <br />00 0 13 8-6 00) <br />F <br />FACILITY NAJME6 EPOL �n C le, jvfj. <br />g A4 i <br />A <br />C <br />-I <br />ADDRESS /9 <br />9=o iw. 4D),e- !7-5 Z1L4 <br />L <br />CROSS STREET <br />Ile <br />T <br />OWNER/OPERATOR 30100 fa4,, r. <br />PHONE <br />Y <br />CONTRACTOR NAME <br />PHONE I <br />x <br />N <br />CONTRACTOR 'ADDRESS X73 -r rec—i f -A557 vit-a CA LIC I CLASS <br />2 <br />INSURER�SM WORKICOMP.1 <br />A---- <br />- ---- <br />C <br />'T <br />FIRE IIIIIIIS <br />'I �, j Oq AU "4. F, V"L 11RIII IIINGPTR <br />. 0 LABORATORY WE <br />14) PHONE I got, <br />R s n i � 17am Aar ,Vq <br />SAMPLING FIRMt SAMPLING METHOD ur'DsrP- <br />d 144yzy� C4 1 <br />w47-&rz- L a -lam <br />TANK 10 1 TANK SIZE CHEMICALS STORED CURRENTLY CHEMICALS STORED PREYIOUSL <br />T <br />Lc,*D�5D , z jzv,/0 <br />A J 9Z S Xv Lf <br />-------------- L� <br />L�L3-1 D4C- L <br />- - - <br />------------------------------ <br />---------------------------- - <br />39 -- - ----------------------- <br />- <br />LIST ADDITIONAL TANK INFORMATION AS NEEDED ON SEPARATE FORM <br />P, APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br />�EATTACHNENT WITH CONDITIONS) <br />RE HAKE <br />A PLAN REVIE4ERS DATE <br />...... . . ---------------------------- <br />----- ------------- <br />APLICANT HOST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br />:OF TK SAN JOAQUIN LOCAL HEALTH DISTRICT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT <br />IM -THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH MANNER AS TO BECOM <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING; '?CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJEC <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. <br />CALL FOR INSPECTIONS AT LEAST 48 HOURS IN ADVANCE <br />)LD1 <br />- -------------------------------------------------DATE �� 1_ _ - <br />__Ej --------- <br />Of6 8 <br />COMP 1 .LOC C DE j DIST CODEJ AMOUNT DUE] AMOUNTRcYD Cki/CASH I RCYO BY I DATE RCYD PERMIT I <br />L m <br />